Health Insurance and the States: A Closer Look

Last week we showed how, two years into Obamacare, there are still millions of uninsured Americans.

The article and maps, which showed where uninsured Americans still live, generated many comments and questions. Here, we respond to a few of them.

Why did some states seem to look so much worse in 2015 than they did in 2014?

If you moused over our big map, you could see that some parts of the country appear to have higher numbers of people without health insurance this year compared with last year, particularly in the Southwest, the Great Plains states and some places in the South. A chart summarizing the three-year trends for those states seems to show some backsliding.

It’s not totally clear what’s going on, and the factors explaining the increases may differ by state. But there are a few possibilities.

First, it may be that the uninsured numbers we published last year were too low in a few places. Our maps drew on estimates calculated by Enroll America, a group devoted to signing people up for new coverage, and Civis Analytics, a data firm. Those groups are updating and refining their model every year. (For more on the math behind the numbers, read this article from last year.)

Since the 2014 numbers were published, the Census Bureau published its own estimates of the uninsured rates in the states. It turns out that several of the places showing a rise in the Enroll uninsured numbers are also ones where Enroll and the census disagreed about the 2014 uninsured rate by more than three percentage points. Among them are Alaska, Nevada, Texas and New Mexico. When it comes to those states, it may be more useful to look at what’s happened between 2013 and this year than to look at the three-year trend. Enroll uses a combination of survey results and demographic data to estimate who has health insurance, and this year’s survey included more people than last year’s.

“I think that it’s possible that a bit of this is explained through a larger survey and better methodology,” said Ed Coleman, Enroll’s director of data and analytics. “But I don’t think that is the whole story.”

In other states, Enroll thinks increases in the uninsured rate may be real and worth tracking. The places that showed increases tend to be more Hispanic, more rural and poorer than other parts of the country. Those factors may cause people to drop out of health insurance at higher rates than other Americans, since they may have more income volatility or difficulty understanding letters from insurers or government officials. Our colleague Abby Goodnough recently wrote an article about insurance dropouts, focused on Mississippi. “When you owe on your house, on your truck, when you’re a single parent of a college student and you have other bills, it just doesn’t work,” Stephanie Douglas, who gave up her health insurance this year, told Abby.

Mississippi was one of the states where Enroll also saw the uninsured rate go up. Several of the states with attrition also tended to have a lot of migration, from other states and from other parts of the world. As those new people have swollen populations in places like Florida, they may have also increased the rate of people with no health insurance.

Why does the uninsured rate look so high on Indian reservations?

If you look at our map, counties with Indian reservations tend to look dark purple, suggesting that native populations are particularly lacking in health insurance. It’s not just South Dakota. You can also see the pattern in parts of inland Alaska, and northeastern Arizona, among other places. The data here are both accurate and slightly misleading.

The survey question used to power the model was “Do you have health insurance?” Native Americans tended to answer that question with a no, even though many did have access to a form of government health care.

It’s true that Native Americans and Native Alaskans have ways of accessing health care without relying on traditional health insurance. The Indian Health Service provides doctors and hospitals for native populations living in certain areas of the country. But those populations often still struggle to obtain adequate health care. Research has shown that native populations are in poorer health and have more difficulty getting care compared with the rest of the country’s population. That’s why the Affordable Care Act was devised to offer additional insurance options to native populations. Under the law, people eligible for care from the Indian Health Service can also sign up for Medicaid or subsidized health insurance in the Obamacare marketplaces, and can get extra help paying for co-payments and deductibles. They don’t need to give up access to the Indian Health Service if they also get health insurance.

Didn’t Montana and Alaska Expand Medicaid?

Our map included black outlines of states that had expanded Medicaid when Enroll America and Civis Analytics conducted its survey this May. At that time, neither state had moved forward with a Medicaid expansion. But things have changed. Alaska’s governor pushed through a Medicaid expansion plan that went into effect in September. On Monday, just after our article published, the Department of Health and Human Services approved a Montana plan to expand that state’s program in January. Those changes mean that more residents of those two states are likely to have health insurance in the next year. It also means that next year’s map may have more black outlines.